Provider Demographics
NPI:1023390432
Name:WINN, KEN
Entity Type:Individual
Prefix:
First Name:KEN
Middle Name:
Last Name:WINN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 ISLAND RD
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33617-6330
Mailing Address - Country:US
Mailing Address - Phone:813-215-7236
Mailing Address - Fax:
Practice Address - Street 1:414 ISLAND RD
Practice Address - Street 2:
Practice Address - City:TEMPLE TERRACE
Practice Address - State:FL
Practice Address - Zip Code:33617-6330
Practice Address - Country:US
Practice Address - Phone:813-215-7236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-12
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-08-4581103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst